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    Diagnostics Of Alcohol Abuse Episode-6

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    Diagnosis Of Alcohol Abuse

    Friends and family members of the alcoholic are often the first to notice problems and seek professional help. Often the alcoholic does not realize the seriousness of the problem or denies it. Some signs cannot go unnoticed, such as job loss, family problems or fines for driving under the influence of alcohol. Addiction is indicated by symptoms such as withdrawal, injury from accidents, or fainting.

    The American Psychiatric Association has developed rigorous criteria for the clinical diagnosis of abuse and dependence. The Diagnostic and Statistical Manual IV (DSM-IV) defines abuse as:

    A maladaptive pattern of substance use resulting in clinically significant impairment or distress, manifested by one (or more) of the following, occurring within a 12 month period:

    1. recurrent substance use resulting in failure to meet important obligations at work, school, or home (for example, repeated absences or poor job performance related to substance use; absences, suspensions, or expulsions from school related to substance use; neglect of children or home)
    2. recurrent substance use in situations where it is physically dangerous (for example, driving a car or operating machinery while impaired by substance use)
    3. recurring legal issues related to drug addiction (for example, arrests for drug-related disorderly conduct)
    4. continued substance use despite persistent or recurring social or interpersonal problems caused or exacerbated by the effects of the substance (eg, arguments with a spouse about the consequences of intoxication, physical fights)

    The symptoms have never met the criteria for substance dependence for this class of substances.

    [DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, ed. 4. Washington DC: American Psychiatric Association (AMA). 1994.]

    Most often, abuse is diagnosed in people who have recently started consuming alcohol. Over time, abuse can turn into addiction. However, some alcohol users abuse alcohol for long periods of time without developing addiction.

    Alcohol Dependence is suspected when alcohol consumption is accompanied by the following signs:

    1. Abuse
    2. compulsive drinking behavior
    3. Tolerance
    4. Cancelation

    The DSM-IV defines Alcohol dependence in the following words:

    A maladaptive pattern of substance use, resulting in clinically significant impairment or distress, manifested by three (or more) of the following, occurring at any time during the same 12-month period:

    • tolerance, defined by one of the following:

    1. a need for significantly larger amounts of the substance to achieve intoxication or the desired effect
    2. markedly diminished effect with continued use of the same amount of substance

    1. the characteristic withdrawal syndrome of the substance
    2. the same substance (or a closely related substance) is taken to relieve or prevent withdrawal symptoms

    • the substance is often ingested in larger amounts or for a longer period of time than intended
    • there is a persistent desire or unsuccessful efforts to reduce or control substance use
    • a large amount of time is spent in activities to obtain the substance, use the substance, or recover from its effects
    • important social, occupational, or recreational activities are given up or reduced due to substance use
    • continues to use the substance despite knowing that he has a persistent or recurring physical or psychological problem that may have been caused or exacerbated by the substance (eg.

    [DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, ed. 4. Washington DC: American Psychiatric Association (AMA). 1994.]

    Evaluation

    The doctor relies on interviews and self-report questionnaires to assess the amount and frequency of alcohol consumption. The questions relate to two aspects:

    1. consequences of alcohol
    2. Perceptions of consumption behavior

    Doctors determine the risk of abuse and dependence based on how much and how often the patient drinks. The definition of moderate drinking differs for men and women:

    • Men 4 to 14 drinks per week
    • Women 3 to 7 glasses per week

    A drink contains 12 grams of alcohol (eg 12 oz beer, 5 oz wine, 1.5 oz 80 degree alcohol). Typical risk assessment questions include:

    1. How many days per week do you drink alcohol ?
    2. On a typical drinking day, how many drinks do you have?
    3. What is the maximum number of drinks you have had on any given occasion in the past mont
    The CAGE questionnaire is commonly used to determine the risk of alcohol-related problems:

     C - Have you ever felt the need to reduce your alcohol consumption?

     A - Have people bothered you by criticizing your drink form?

     G - Have you ever felt bad or guilty about drinking?

     E - Have you ever had a revelation, a drink in the morning to calm your nerves or get rid of a hangover?

    A "yes" answer indicates a risk of alcohol abuse and/or addiction problems; more than a "yes" indicates a high probability.

    The Identification of Alcohol Use Disorders (AUDIT) and Assessment of Mental Disorders in Primary Care (PRIME-MD) are based on the CAGE. The five-point trauma scale focuses on the problem of alcohol use in both men and women. The T-ACE and TWEAK are designed to identify alcoholism in pregnant women.

    As these less formal interviews and questionnaires carry a risk of under-reporting, additional tests are used to prompt for information, particularly if the patient is evasive or intoxicated at the time of the interview:

    1. The Michigan Short Alcohol Screening Test (S-MAST) determines general alcohol abuse.
    2. The Short Questionnaire of Data on Alcohol Dependence (SADD) determines the severity of addiction.

    Once abuse or addiction is verified, the doctor administers a comprehensive assessment to develop a treatment plan. The assessment includes a detailed medical and psychological history of the person. The doctor may request copies of medical records and interview family members.

    Differential diagnosis

    The physician should rule out medical conditions that cause intoxication and withdrawal symptoms, such as the following conditions:

    1. head trauma
    2. hypoglycemia
    3. an electrolyte imbalance
    4. Diabetic acidosis and ketoacidosis
    5. Meningitis
    6. Neurological conditions such as multiple sclerosis
    7. Pneumonia
    8. raise

    If a patient suffers from any of these conditions, they may be disoriented, unable to carry on a conversation, have a short attention span, or have trouble walking or maintaining balance. In cases of head trauma and stroke, the patient may be unconscious.

    Diagnosis also includes assessments for depression and anxiety disorders, which often coexist with alcoholism. Abuse of other intoxicants, such as benzodiazepines and barbiturates, is common. The presence of a mixed drug and alcohol problem should be determined.

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